Healthcare Provider Details

I. General information

NPI: 1457573933
Provider Name (Legal Business Name): CONNECTICUT GERIATRIC SPECIALTY GROUP, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2007
Last Update Date: 09/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 ABRAHMS BOULEVARD
WEST HARTFORD CT
06117
US

IV. Provider business mailing address

1 ABRAHMS BOULEVARD
WEST HARTFORD CT
06117
US

V. Phone/Fax

Practice location:
  • Phone: 860-523-3854
  • Fax: 860-523-3828
Mailing address:
  • Phone: 860-523-3854
  • Fax: 860-523-3828

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. DAVID HOULE
Title or Position: VICE PRESIDENT/CFO
Credential:
Phone: 860-523-3895